Neonatal dacryocystoceles are an uncommon cause of congenital nasolacrimal duct obstruction (CNLDO). Patients typically present with a bluish cystic mass below the area of the medial canthus soon after birth and are often found to have intranasal cysts, Dacryocystoceles can also be complicated by infection, leading to dacryocystitis.
The current treatment modalities for neonatal dacryocystoceles range from conservative medical management, such as antibiotics and massage, to surgical intervention. There is little consensus regarding the optimal management or timing, but current recommendations favor early surgical intervention due to the risk of associated complications. Historically, procedures were performed in the operating room under general anesthesia by a pediatric ophthalmologist and consisted of nasolacrimal duct probing and lacrimal irrigation with or without nasal endoscopy and intranasal cyst marsupialization by a pediatric otolaryngologist.
In cases of simple CNLDO without dacryocystoceles, initial conservative treatment is preferred due to a high rate of spontaneous resolution in the first year of life. Conservative therapy typically consists of a combination of lacrimal massage, warm compresses and topical or systemic antibiotics. However, success rates of conservative measures for CNLDO with associated neonatal dacryocystocele are variable, ranging from 14 to 76% with an average of 23% reported in the literature. Surgical intervention is warranted in the management of CNLDO caused by neonatal dacryocystoceles when associated with secondary infections such as dacryocystitis and pre-septal cellulitis.
The most common surgical approach described for the management of neonatal dacryocystoceles is NLD probing and irrigation by a pediatric ophthalmologist. This procedure can be accomplished in the office without general anesthesia, but failures are usually taken to the operating room for a repeat procedure. In the setting of dacryocystoceles, failure rates of a single probing have been reported in 22-40% of patients and are hypothesized to be due to redundant mucosa within the intranasal cyst that is incompletely removed with simple probing or puncture.
In the setting of a clear clinical diagnosis of CNLDO due to a dacryocystocele, cross-sectional imaging is not routinely obtained. The minimally invasive procedure can be performed safely and effectively even in the presence of a superimposed infection. In the case of dacryocystocele without dacryocystitis, awake endoscopic intranasal cyst marsupialization (EICM) should still be considered, as it is a low-morbidity procedure and the risk of dacryocystitis in the setting of dacryocystocele is high. Another reason to consider early intervention is that because neonates are obligate nasal breathers, intranasal cysts can contribute to airway obstruction and poor feeding.
Neonatal dacryocystoceles are successfully treated through nasal endoscopy with simple endoscopic intranasal cyst marsupialization. Avoidance of general anesthesia and NLD probing or irrigation may simplify and decrease the cost of dacryocystocele and intranasal cyst management.